DA Form 5412-r Waiver of Compensation Statement

DA Form 5412-r - also known as the "Waiver Of Compensation Statement" - is a United States Military form issued by the Department of the Army.

The form - often mistakenly referred to as the DD form 5412-r - was last revised on April 1, 1985. Download an up-to-date fillable PDF version of the DA 5412-r down below or look it up on the Army Publishing Directorate website.

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WAIVER OF COMPENSATION STATEMENT
For use of this form, see AR 690-300; the proponent agency is DCSPER.
I, the undersigned, have offered my services to the United States
Government as an expert or consultant to serve without compensation.
Should my offer be accepted, I, my heirs, and assigns discharge and
release the United States Government forever from any claims, suits,
or demands for compensation in connection with any such services.
TYPED NAME OF APPOINTEE
SIGNATURE OF APPOINTEE
DATE
TYPED NAME OF WITNESS
SIGNATURE OF WITNESS
DATE
DA FORM 5412-R, APR 1985
APD LC v2.01ES
WAIVER OF COMPENSATION STATEMENT
For use of this form, see AR 690-300; the proponent agency is DCSPER.
I, the undersigned, have offered my services to the United States
Government as an expert or consultant to serve without compensation.
Should my offer be accepted, I, my heirs, and assigns discharge and
release the United States Government forever from any claims, suits,
or demands for compensation in connection with any such services.
TYPED NAME OF APPOINTEE
SIGNATURE OF APPOINTEE
DATE
TYPED NAME OF WITNESS
SIGNATURE OF WITNESS
DATE
DA FORM 5412-R, APR 1985
APD LC v2.01ES

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